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Table of Contents   
CASE REPORT  
Year : 2012  |  Volume : 5  |  Issue : 6  |  Page : 587-590
Cervical spine tuberculosis and retropharyngeal abscess in an adult Nigerian


1 Department of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria
2 Department of Radiology, Federal Medical Centre, Idi-Aba, Abeokuta, Ogun State, Nigeria

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Date of Web Publication20-Mar-2013
 

   Abstract 

Globally, there has been an increase in the incidence of tuberculosis by 2.2 million from 1997 to 2005 and 95% of this is occurring in developing countries. Tuberculosis of the cervical spine is rare. To present our experience with a case of cervical spine tuberculosis. We present a case report of tuberculosis of the C3/C4 cervical spine associated with retropharyngeal abscess in a 36-year-old Nigerian woman. The disease was also associated with pulmonary tuberculosis. Neck pain, neck stiffness, radicular pain, especially to the left shoulder and wasting of the muscles of the hand, were the main features. Our patient improved on anti-tuberculous therapy and conservative supportive care. This case stresses the usefulness of simple pain cervical X-radiograph, especially in environments like ours where sophisticated investigations are either not available or beyond the reach of most patients. Conservative management in our patient resulted in remarkable improvement.

Keywords: Cervical spine, Nigeria, retropharyngeal abscess, Tuberculosis

How to cite this article:
Ogah OS, Owolabi MO, Akisanya CO. Cervical spine tuberculosis and retropharyngeal abscess in an adult Nigerian. Ann Trop Med Public Health 2012;5:587-90

How to cite this URL:
Ogah OS, Owolabi MO, Akisanya CO. Cervical spine tuberculosis and retropharyngeal abscess in an adult Nigerian. Ann Trop Med Public Health [serial online] 2012 [cited 2019 Dec 15];5:587-90. Available from: http://www.atmph.org/text.asp?2012/5/6/587/109286

   Introduction Top


Tuberculosis (TB) remains an important disease condition in many developing countries of the world, especially in people below the age of 20 years. Its incidence is also increasing in the developed countries as a result of the emergence of HIV/AIDS and increase in immigrant populations.

Skeletal tuberculosis constitutes 3-5% of all cases of TB and 10-15% of extra-pulmonary TB. [1] TB spine is the most common form of skeletal TB. It is the most dangerous manifestation of TB due to involvement of the spinal cord and the resultant neurologic impairment. The dorsolumbar region is the most frequently involved with D.11 vertebra being most often affected from previous report in Nigeria. [2],[3] Cervical spine TB is, therefore, rare comprising 2-3% of cases of TB spine. [4]

Moreso its co-existence with retropharyngeal abscess is rarer. To the best of our knowledge, less than 30 cases have been reported in medical literature. [5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23] This is the first case of retropharyngeal abscess complicating cervical spine TB in an adult in our environment.

We report a case of cervical spine tuberculosis co-existing with retropharyngeal abscess in a Nigerian woman.


   Case Report Top


A 36-year-old Nigerian woman presented with a month history of neck pain and neck stiffness and 6 day history of weakness in the upper and lower limbs worse on the left. The neck pain was initially mild but later became severe with associated radicular pain to the left shoulder. Six months earlier, she had coughed for two months.

There was history of weight loss but no fever or excessive night sweats. No antecedent history of trauma to the head and neck region. No history of urinary or fecal incontinence, cough, or breathlessness. She had dysphagia as well as odynophagia.

Physical examination revealed a young woman who was pale, afebrile, anicteric with no significant peripheral lymphadenopathy. There was marked weight loss and fullness in the retropharyngeal area.

Central nervous system examination revealed that she was conscious and alert and well-oriented. She had neck stiffness and limited neck movement. There was wasting of the small muscles of the hand and clawing of the fingers worse on the left. She was quadriparetic with gross muscle power. Muscle power was grades 3 and 5 on the left and right, respectively. She had global hyperreflexia with sustained ankle clonus.

There was bilateral apical flattening on chest examination and apical bronchial breath sounds and crepitations.

Examination of the cardiovascular system and abdomen did not reveal any significant abnormalities.

Her chest radiograph showed reticulo-nodular shadows in both apices but worse on the left.

Radiograph of her cervical spine showed [Figure 1]: Straightening of the normal cervical loidosis, collapse, and sclerosis of C3 and C4 vertebrae and obliteration of the C2/C3 and C3/C4 disc spaces. Other findings include widening of the prevertebral soft tissue from C1-C5 with resultant narrowing of the adjoining airway (oropharynx and hypopharynx). There was also sclerosis of the pedicles of C3/C4 vertebrae and osteophytic spurring of the antero-superior margin of C4.
Figure 1: Ateral view of X-ray of the cervical spine, showing straightening of the normal cervical loidosis, collapse, and sclerosis of C3 and C4 vertebrae and obliteration of the C2/C3 and C3/C4 disc spaces

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Her ESR was 72 mm/hr (Westergreen method). She had relative lymphocytosis, and her HIV screening was non-reactive.


   Discussion Top


TB of the spine is an ancient disease. It was reported in 5000 year old Egyptian mummies. The first scientific description in medical literature was by Percival Potts in 1778, hence the name Pott's disease of the spine. The cervical spine is affected in about 2-3% of spinal TB. It has the propensity to cause neurological deficits and instability. [20]

The mycobacterium, which is carried hematogenously or lymphatically, invades the anterior and subchondral portions of the body of the vertebrae. This leads to osteomyelitis. As the infection progresses, the periosteum and the longitudinal ligament is lifted off the surface of the vertebral bodies. Caseation necrosis and destruction of the vertebrae and abscess formation ensues. When the abscess formed remains close to the vertebrae, it presents as prevertrebral or paravertebral abscess on plain radiograph. The abscess may track distally along tissue plains to form cold abscess. The abscess may bulge into the mouth or the pharynx resulting in odynophagia, dysphagia, pharyngeal discomfort and rarely airway obstruction, respiratory distress and twelfth-nerve palsy. [8],[10],[24],[25],[26]

The retropharyngeal area is a potential space in the facial planes, sandwiched between the buccopharyngeal facia and the prevertebral facia. The contents among others include prevertebral lymph nodes (in children) and areola tissue. The former forms part of the lymphatic drainage of the head and neck region, which may explain why retropharyngeal abscess is common in children.

Acute retropharyngeal abscess is, therefore, very uncommon in older children and adults, except as a consequence of trauma to the head and neck region.

Although a rare combination, TB is the commonest cause of chronic retropharyngeal abscess in developing countries with less than 30 cases reported in medical literature. It is commoner in developing countries or in immigrants in developed countries. [6]

It is characterized by chronic and insidious onset. Common clinical manifestations include neck pain, neck stiffness, dysphagia, hoarseness of voice, sensation of foreign body in the throat, and dyspnea. Primary oropharyngeal TB is very rare and constitutes about 0.9% of TB of the upper respiratory tract in one series. [7]

The propensity of cervical lesions to cause neurologic deficit may explained by the fact that the spinal canal in this region is small relative to the diameter of the cervical cord. The mechanism of neurologic symptoms in cervical spine TB include: local inflammatory response, tuberculous vasculitis and ischemia, subluxation of the vertebrae, abscess on the spinal cord or nerve root, and impingement of the discs.

Specific investigations include plain X-radiograph of the cervical spine, aspirate of abscess for acid fast bacilli, computerized tomography scan (CT scan), and magnetic resonance imaging (MRI) of the cervical spine.

Plain X-radiograph may show narrowing of the disc space, loss of paradisc space, kyphotic deformity, and soft tissue shadow. [27] CT scan of the cervical spine will show clearly lysis and destruction of the vertebral body. It may also reveal paraspinal granular tissue. [28] MRI is the most sensitive tool in evaluating abnormalities in spinal tuberculosis, especially gadolinium-enhanced T1-weighted image because it provides better bone enhancement. MRI is useful in evaluating the presence and extent of compression of neural structures by the adjacent bone and soft tissues.

In one study, [29] MRI revealed gross abnormalities in 63% of subjects with TB spine who had normal plain radiographs. In two other studies, [27],[30] MRI was used to show that 60% degree of compression results in significant neurological deficit. Al Mulhim et al,[31] proposed that less than 50% narrowing produces mild to moderate neurologic deficit and greater than 75% narrowing causes severe neurologic impairment.

The mainstay of treatment is anti-TB therapy. Although optimum treatment for tuberculosis of the spine is still a subject of debate, management of patients should be individualized and this generally depends on location and extent of the lesion, spinal stability, presence or absence of spinal deformity, and severity of neurologic impairment.

According to the findings of the Medical Research Council prospective study on TB spine, [32],[33],[34],[35] overall outcome was similar for both conservative (medical) and operative treatments. The report, however, advocated that patients with neurologic deficits, unstable spine, kyphosis, abscess, and intractable pain require surgery. Surgical management offers the advantage of an early ambulation, early neurologic recovery, less hospitalization, and less deterioration of the angle of kyphosis. The best surgical approach according to the report is the Hong-Kong operation (this involves excision of the diseased bone and replacement of the gap created with a bone graft.)

In conclusion, TB is the commonest chronic infection in Nigeria. Cervical spine TB is rare, more so when it co-exist with retropharyngeal abscess. Although we were not able to establish a microbiological diagnosis of the abscess, we believe that it is most likely the diagnosis because of the length of the illness, TB in another site (pulmonary), the typical cervical bone lesion, and the excellent result with anti-TB therapy.

Our report is similar to those of other workers. It also stresses the usefulness of simple plain cervical X-radiograph, especially in environments like plain where sophisticated investigations are either not available or beyond the reach of most patients.

Conservative management in our patient resulted in an excellent improvement.

 
   References Top

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Correspondence Address:
Okechukwu S Ogah
Department of Medicine, University College Hospital, PMB 5116, Ibadan
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.109286

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